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Clinical vs psychotherapy Clinical vs psychotherapy Document Transcript

  • Special Section: Revisiting the Clinical Psychology Curriculum Section spéciale : Regard neuf sur le programme détudes en psychologie clinique Psychology as a Health-Care Profession: Implications for TrainingWOLFGANG LINDEN care from mental health care is artificial, counterpro-JANINE MOSELEY ductive to the well-being of patients, regressive, andYVONNE ERSKINE antithetical to modern psychology and medicine alike.The University of British Columbia Note also that this article is in part based upon the personal views and experiences of the authors, an aca- demic clinical psychologist and two psychology gradu-Abstract ate students, whose views have been shaped by manyThis article places a magnifying glass on psychology’s cur- years of academic training and teaching, clinicalrent training realities in the context of global health devel- supervision and research design, and – in the case ofopments, particularly those of the Canadian health-care the first author – being involved in professional orga-system. The authors argue that curriculum review and revi- nizations and serving as a clinical program director.sion is needed to solidify psychology as a true health care This article does not portend to describe “just theprofession; such a review should be proactive and must facts”; rather, it is often opinionated, it does not offerconsider the likely changes in our overall health-care sys- ready solutions, and its main purpose is to trigger atem. In preparing for anticipated changes in health care, it lively discourse. It imposes a magnifying glass on ouris proposed that curricula modifications be made to better current training realities in the context of more globalreflect how psychology can contribute (in a broad fashion) health-care changes, and then reflects on the implica-to the health of Canadians. Two particular models for psy- tions of this analysis for possible changes in universitychology’s future role are offered for discussion: a) a modi- curricula.fied, comprehensive parallel/vertical model that sees psychol- The practice of psychology cannot stay stagnant ifogists similar to other health-care providers; versus, b) a the structure of health care is itself changing or elsemore innovative horizontal/cross-cutting model in which psy- we are manufacturing our own erosion. Universities,chologists provide a unique blend of education, innova- therefore, need to be training psychologists to betion, teaching, system consultation, prevention, as well as ready for such changes. Given that, arguably, no per-direct service provision, to patients with physical and men- fect health-care system exists anywhere world-wide,tal health problems. changes will have to arise from vivid discussion and forethought, will require courage and political will, and will inevitably carry some risk for failure. Despite risks inevitably embodied in any change, it is posited The objectives of this article are to reflect upon the here that the last thing we can afford to do at this timestatus quo of psychology’s role in health care, upon is to stick our heads in the sand while we let othersthe need to be prepared for massive changes in health decide our fate. Figure 1 illustrates where in thecare in Canada, and upon the desire for the profes- process of change we see the place of this article; insion of psychology to play a major role in these particular, we want to prevent the “crossed-out option”changes, including efforts to position itself in a more in this sequence model from becoming reality, andsubstantial role than was awarded to us in the past. encourage proactive planning so as to maintain con-This background then serves to enunciate recommen- trol over the future of our profession.dations for how professional training can and must The timing of this attempt at provoking discussionchange to map onto system changes and to maximize about a changed role for psychology is not at all acci-the potential of psychologists in the marketplace. As dental. There is widespread consensus amongthe title suggests, this article explicitly defines psychol- Canadians that the Canadian health-care system is inogy as a Health-Care Profession rather than limiting it to need of an “overhaul.” Although at the very conserva-a Mental Health-Care Profession. In fact, the position tive end of the political spectrum, politicians claimtaken here is that any separation of physical health that the current system is beyond repair, this not a common belief; most Canadians think that the system needs, and is capable of, extensive revision (Rachlis &Canadian Psychology/Psychologie canadienne, 2005, 46:4, 179-188 Kushner, 1994). The potential direction of such revi-
  • 180 Linden, Moseley, and Erskine Psychology plans its own future now, and Actively participates in health care system changes Health Care A Revised Health Psychology reacts System Now Care System and adjusts its training to the new system realities Figure 1.sions has been laid in two major commission reports, face budgetary constraints, their departments of psycholo-namely the so-called Romanow and Kirby commission gy are frequently reduced or eliminated. Moreover, manyreports (www.hc-sc.gc.ca/english/care/romanow/ low- and middle-income individuals, together with peoplehcc0086.html; www.parl.gc.ca/common/Committee_ who are unemployed and/or those who do not have pri-SenRep.asp?Language=E&Parl=37&Ses=2&comm_id= vate health insurance, cannot afford to pay for private psy-47). Neither of these reports makes any explicit men- chological services which are not covered under publiclytion about the role of psychology despite the fact that funded provincial health care insurance. (Kirby Interimpsychology had made numerous submissions to these Report, 2004, p. 161)commissions. Regardless, our profession is readilyembedded in the commissions’ suggestions that the The Kirby Commission on Mental Health is prepar-entire system be more multidisciplinary, more preven- ing to produce a second report on our mental healthtive, and more responsive to subjective patient needs. system, and in this regard is seeking submissions on At the time that these commission reports were system modification and improvement suggestions; wereleased, psychologists had good reason to complain think that it is critical for psychology to participate.that they were not much of a dot on the public’s and An important question to consider for this discus-politicians’ radar screens. Fortunately, this situation sion is how the health of Canadians has changed overhas changed since the release of the Interim Report of time and what consequences that has (or needs tothe Standing Senate Committee on Social Affairs, have) for the health-care system. The answer to thisScience, and Technology (2004a,b,c)(below simply question also provides the context and rationale forreferred to as the Kirby Interim Report, 2004), which suggesting curriculum changes in psychology. Manyspecifically focuses on mental health and the mental comparable health trends have been observed inillness service system. Here, it is recognized that psy- Canada and in the U.S. (see Kenkel, DeLeon, Mantell,chology is an underutilized resource, that the current Orabona, Angie, & Steep, 2005) and yet the U.S. hasfunding system forces many people to apply for psy- seen a far greater cost explosion than Canada. At leastchological services out of their own pockets, and that among Canadians, there is agreement that the for-access to psychological services is not equitable or uni- profit system (and extraordinarily complex reimburse-versal: ment structure) in the U.S. accounts for much of the 50% greater per capita health expense that AmericansFor psychological services, equality of access appears to be have to contend with. Over and above this particularthe major problem. Publicly funded psychology services difference, both countries have seen frighteningly ris-through hospital or mental health clinic programs are ing costs for health care. These have been attributedspotty and limited in their availability. As general hospitals (at least in part) to an aging population that survives
  • Psychology as a Health-Care Profession 181more life-threatening illnesses and whose longer life healthy eating) are greatly weakened by stress,expectancy comes “packaged” with the need to man- which in turn can be modified by psychologicalage chronic illnesses. Health-care reviews like the means (for reviews see Linden, 2004; Vitaliano,Romanow and Kirby commission reports routinely Zhang & Scanlan, 2003).point out that the largest portion of health-care dol- • Anxiety and depression, which unfortunately arelars are spent, for a given patient, in the last year of his frequent psychological problems, are key emotion-or her life, often extending life at great cost at a time al contributors to substance abuse; both anxietywhen patients themselves often no longer want dra- and depression can be identified though screeningmatic measures. and can be psychologically treated. Therefore, we posit that the mission for psychology • The various health-care commission reports do notnow, and in the future, is to fulfill Lalonde’s (1974) provide indication that psychiatric morbidity is sud-quest to “add life to years” given that medicine has in denly rising. At the same time, however, there is nogood part succeeded to “add years to life.” The poten- indication that previous prevention and treatmenttial for cost savings to the health-care system that can efforts have reduced the incidence of psychiatricarise out of better management of risk factors and out diseases. The Kirby Interim Report cites the esti-of more efficient management of the chronically ill, mated cost of mental illness in Canada for 1998 athas been documented throughout a rich literature. A $14.4 billion. Of particular concern to the varyingfew examples might help to highlight the importance commissioners were increases in substance abuseof adding professional psychologists’ skills to health disorders, cancer incidence, and diabetes.care rather than just involving them in delivery ofmental health services: Review of Current Training Models and• The annual cancer incidence, in British Columbia Identification of Psychology’s Strengths alone, is about 20,000 (or approximately 500/ In order to make reasonable suggestions for 100,000; www.bccancer.bc.ca). Seventeen per cent changes in psychology training against the back- of the cancer population has lung cancer, and it is ground of a changing health care system, it may be estimated that 85% of lung cancers are caused by opportune to review training curricula and profession- smoking. Heavy smokers carry a risk ratio of 120:1 al identities. By doing so, we will be in a better posi- for developing lung or throat cancer relative to tion to respond appropriately to changes in health nonsmokers. Yet, smoking is both preventable and care, and be proactive in contributing to a revised stoppable, and psychology has made major contri- health-care system and assure our place within it. butions to the prevention and treatment of smok- ing behaviour. Clinical Versus Counseling• Many patients who survive a heart attack eventually Psychologists who provide health care have typically develop congestive heart failure (CHF). CHF graduated from well-defined, and mostly often accred- patients account for a large portion of expensive ited, training programs in Clinical or Counseling emergency hospitalizations. A group of Swiss Psychology. A typical graduate program in Clinical researchers analyzed the causes of such emergen- Psychology looks like this: cies in 111 consecutive patients (Wagdi, Vuilliomonet, Kaufmann, Richter, & Bertel, 1993) Year 1: Research Methods, Statistics, Assessment I, and found that the primary cause for readmission Treatment I, Psychopathology, Ethics was poor compliance with treatment regimens Year 2: Assessment II, Treatment II, 2 Breadth (e.g., irregular use or complete refusal of medica- Courses, Practicum, Master’s thesis tions, and excess salt and fluid intake). Year 3: Optional Breadth and Statistics Courses, Psychologists can draw on a rich literature to help Assessment and Therapy courses, Practicum with developing programs to improve such adher- II ence, improve patient quality of life, and reduce Year 4: Breadth courses, Comprehensive exams, treatment costs at the same time. PhD thesis• There is a growing epidemic of diabetes, which is Year 5: Full-year internship largely preventable and controllable through behavioural change activities around exercise and The typical reader, of course, knows that this five- nutrition, moderated by psychological well-being year time frame is optimistic and that a combined (Barrera, Toobert, Glasgow, & Angel, in press). MA/PhD realistically takes between six and seven years• Health behaviours (like regular exercise and to complete, largely because the thesis research
  • 182 Linden, Moseley, and Erskineprogress is affected by a slew of uncontrollable factors, areas that were correctly described as “experimen-and also because many students need to work part- tal programs” and were designed to lead to acade-time to boost their meager incomes or add voluntary mic/research careers. At some point in their train-clinical hours to make them more compatible for the ing, these individuals discover that they would pre-job market. fer to provide clinical services upon graduation While there is much debate across university cam- rather than be pure academics or researchers. Theypuses about differences between Clinical and then scramble to somehow acquire clinical train-Counseling Psychology, these differences tend to dis- ing. This can occur in the context of a post-PhDappear as students graduate and start practicing. In respecialization program (which are rare), or alter-university, Clinical Psychology places a strong empha- natively, graduate-level students compile a packagesis on preparing students for work with more severe of courses and workshops that are accessible topsychopathology, using mostly cognitive-behavioural nonapplied students and that have some bearingand interpersonal therapies, and offering consider- on clinical work. However, in the end the trainingable formal training in assessment. Also, Clinical that these students receive usually fails to replicatePsychology tends to embrace more biological bases of the logical, sequential, comprehensive learningbehaviour, and students tend to learn more about psy- process required for becoming a health profession-chopharmacology, neuropsychology, and applications al that is represented in the structured, accreditedof psychological knowledge to physical diseases. As training programs.working professionals, clinical psychologists are likelyto hold hospital-based positions upon graduation. 2) There is also anecdotal reason to believe that someAlternatively, counseling Psychology programs empha- students go into nonapplied programs knowing fullsize more client-centred and systemic approaches, and well that they do not want to be academics and/ortend to prepare students for careers in schools and full-time researchers. Such students hope toout-patient services. However, the single most fre- serendipitously pick up enough clinical skills toquent type of workplace for both clinical and counsel- enable application for registration as psychologistsing psychologists is private practice, and it is argued in the “Clinical” or “Counseling” categories despitethat (especially) in this environment, the originally never actually completing such programs. Theexisting differences between these two types of profes- motive for this second approach arguably arises outsionals gradually fade. For the purpose of this article, of the gross mismatch of demand and supply, inwe will not further distinguish these two types of pro- that clinical and counseling programs can admitfessional designations, as they are not particularly crit- only a fraction of all applicants (due to limitedical for the shared issues that affect all professional resources). The ratio of applications to admissionspsychologists in the world of health care. Below, how- in an accredited clinical program, for example, isever, the reader will find a brief discussion that distin- typically below 10% for a given program. Althoughguishes psychology graduate students from those stu- this figure is discouragingly low, almost all thesedents who do not complete either a structured students apply to multiple programs and ultimatelyClinical or Counseling Psychology program but still a larger number is successful. This figure neverthe-hope and plan to work as psychology health profes- less represents a gross mismatch of demand andsionals. supply.Issues Around Applied Versus Nonapplied Training in In the past, these “patch” approaches have occa-Graduate School sionally been successful when registration require- A difficult issue faced by the registration commit- ments of the provincial colleges were less stringent.tees of colleges of psychologists and potential employ- However, this scenario has almost disappeared asers is what many refer to as “backdoor clinical train- agreements between the Canadian provincial registra-ing.” This concept applies to students who have tion bodies now require demonstration of well-sought out to acquire clinical and counseling skills defined, universal skill sets and knowledge that isand then attempt to register and/or pose as profes- readily acquired only by completing an accreditedsional psychologists without actually completing pro- program in Counseling or Clinical Psychology.grams designated as either a clinical or a counseling Additionally, a final stumbling block for so-calledprogram. This phenomenon is not infrequent and is “backdoor admission” to registration as a clinician isarguably the result of two processes: the now-required one-year internship, which is most difficult to acquire if a student’s background is some-1) Students complete graduate degrees in specialty how unorthodox.
  • Psychology as a Health-Care Profession 183 Changes in Employment Settings schools within the Faculty of Education (applicable to Over the last 30 years, there have been many sys- some Counseling Psychology programs). Some univer-tematic changes in the employment settings of clinical sities that have psychology departments do not havepsychologists in the U.S. (Norcross, Karg, & Prochaska, an associated medical school (for example the1997a,b). The single largest shift has been away from University of Waterloo or Simon Fraser University).outright employment in hospital and community clin- Alternatively, other universities train physicians andics (27% in 1973 but only 17% in 1995) to more and other health professionals but do not offer Clinical ormore private practice arrangements (from 23% in Counseling Psychology programs (e.g., McMaster1973 to 40% in 1995). Employment in universities also University). And then there are universities that offerdeclined over the same three decades from 37% to a wide range of training in the health professions. The28%. What did grow was the category “other” (from home university of the authors (the University of1% to 11% three decades later, by 1995), where British Columbia) actually has 11 different programs“other” encompasses settings such as corrections, make up their health professions training.health maintenance managed-care organizations (in Given that psychology is exceedingly popular withthe U.S.), professional school settings, and child and undergraduates, psychology departments are compar-family services. While we are not aware of a corre- atively large departments within their respective uni-sponding attempt to collect such data in Canada, versities and carry very high student to faculty ratios.trends are anecdotally reported as similar (aside from Understandably, a psychology department with 40-50the nonexistence of health maintenance organiza- faculty members can teach highly diverse undergradu-tions in Canada). While the popular image of private ate and graduate courses. Moreover, it does not needpractice consists of one-on-one interactions of client to farm out much of its teaching nor is it forced towith psychologist, the reality for many private practi- engage in complex collaboration agreements withtioners is much more varied. Their private practice other departments to raise its efficiency and range ofactivities may include such things as disability assess- service offerings. This strength, of course, also impliesments for bodies like Worker Compensation Boards, that interdisciplinary teaching and collaboration maycustody and access assessments in divorce cases, medi- require effort to create and sustain. Occasionally grad-ation of personnel disputes, consulting with police uate programs involve community psychologists (whocommissions on stress inoculation, providing post- are working in hospitals) and private practitioners totrauma debriefing for bank employees who witnessed teach specialty graduate courses or provide clinicala hold-up, or offering contract-based part-time consul- supervision.tation to various ministries. Also, the self-reported primary theoretical orienta- Role of Research Versus Clinical Practice in Various Healthtion of clinicians is now predominantly cognitive- Professionsbehavioural and appears to complement a parallel Clinical Psychology early on adopted a self-defini-decline in preferred psychodynamic orientations tion of following a scientist-professional model that(Norcross et al., 1997a). The common presumption was first enunciated in the 1949 Boulder conferenceabout the reason for this shift is the increasing pres- and has henceforth been called the Boulder modelsure applied by insurance companies to use brief, (Trull & Phares, 2001, p. 51). The Boulder model rec-empirically validated treatments. A significant change ognizes the strong experimental tradition of psycholo-affecting the day-to-day activities of hospital-based psy- gy, and not only acknowledges, but even embraces,chologists is the move towards patient care teams that the realization that our knowledge base is too thin toare often matched with the abandonment of psycholo- jump both feet first into clinical practice. Instead itgy department structures. While there is widespread was, and still is, seen as necessary to learn from everyagreement that patients may benefit from this patient, and to stay on top of rapidly evolving knowl-approach, psychologists often end up the single repre- edge in psychopathology and interventions. Thissentative of their profession on various teams and model has distinct consequences for training, as aneed strong identities and an assertive personality to review of a typical curriculum (see above) reveals thatstand their ground. Repeated anecdotal reports cite a great deal of time and effort during MA and PhDgrowing difficulties with maintaining internship pro- programs is spent on research training. In order tograms in this diffused program delivery model. see how these unique training realities relate to those of other health professions, we conducted an informal Health Professions Training in University survey of faculty and students in the identified 11 Canadian psychologists earn their degrees in clear- health professions found on the UBC campus. Thely defined psychology departments, or sometimes in authors contacted a minimum of one graduate stu-
  • 184 Linden, Moseley, and ErskineTABLE 1 gy, health professions tend to define specific degreePractice Versus Research Training in the Health Professions programs as almost exclusively practice oriented or––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– exclusively research oriented, with the undergraduateProfession Degree % Effort % Effort programs being the practice-oriented ones and the Program Practice Research graduate degree programs being research oriented. Training Training––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– PhD programs outside of psychology are almost exclu-Audiology/Speech Science MA 70 30 sively designed to train for research. Somewhat of an exception is medicine, which grants a doctoral degreeClinical Psychology MA 50 50 but is officially classified as an undergraduate pro- PhD 40 60 gram and offers minimal research training.Counseling Psychology MA 65 35 Psychology, therefore, stands out as, 1) trying to pro- MEd 75 25 vide continuing integration and a balance of research PhD 50 50 and practical skill training throughout MA and PhD training levels, and 2) offering essentially no practicalDentistry DMD 80 20 training at the undergraduate level. BDSc in Dental Hygiene 70 30 What Is To Be Learned From the Review of Changes in MSc 20 80 Health, Health Care, Health-Care Professions, and Training PhD 10 90 Models? MSc/Dip 60 40 Based on our brief review, we summarize below Perio what we believe is relevant with respect to training rec-Dietetics/Nutrition BSc 90 10 ommendations as well as the need to get involved in MSc 0 100 actively shaping the upcoming changes in our health- PhD 0 100 care system.Medicine MD 100 0 We learned that:Nursing BScN 90 10 • Psychology is a potentially critical contributor to all MN 70 30 health care, not just mental health care; PhD 10 90 • A distinction of physical health care versus mental health care is regressive and artificial;Occupational Therapy MOP 80 20 • Psychologists have unique expertise in behaviour MSc 0 100 PhD 0 100 change that is critical for dealing with the growing need for handling chronicity in physical and men-Physiotherapy MPt 80 20 tal illness, and we have a mandate to add “life to MSc 0 100 years”; PhD 0 100 • Training of psychologists for health care needs to be broad, comprehensive, sequential, and planned;Pharmacy BPharm 100 0 • In addition to clinical practice skills for one-on-oneSocial Work BSW 90 10 service delivery, psychologists have unique strength MSW 70 30 in research as well as broad skills and knowledge PhD 20 80 relevant to teaching and consultation.––––––––––––––––––––––––––––––––––––––––––––––––––––––––––– The Future of Trainingdent and one faculty member associated with each of Recommendation 1the 11 programs, and asked the respondents to rate Allocate funding to practitioner training in psychol-the proportion of time that students in various degree ogy such that a better balance is created between whatprograms spend in either training for clinical practice or graduate student applicants want and what programstraining for research careers. They were to express their offer. Following this recommendation does not neces-opinions as a proportion such that 50:50 would mean sarily require new funding and can sometimes be doneequal amounts of time are being spent in practice ver- as a within-department decision. We suggest that psy-sus research training. The results of this brief survey chology programs review the jobs of graduates forare described in Table 1. their various subprograms and consider changing fac- To us, the most striking conclusion from this crude ulty and other resource allocation if there is a clear dis-survey exercise is that, with the exception of psycholo- parity in the placeability of some subspecialty gradu-
  • Psychology as a Health-Care Profession 185ates but not others. Resistance to this suggestion may, 4.2. Psychology training programs should include aof course, arise as some programs will lose resources in course or some content on aging (both normal andthis process. The suggestion to increase the availability abnormal developmental processes).of quality training for psychologists as health practi-tioners should help to balance the supply-demand 4.3. Psychologists’ teaching needs to cover manage-ratio and make it less necessary that students attempt ment of all behaviour that is critical to chronic dis-to get backdoor clinical training. In fact, we posit that eases.a laissez-faire attitude of regulators, department heads,and clinical teachers about backdoor training does not 4.4. Health promotion skills (to occur at a commu-serve us well in making a strong public case for our nity, or even nationwide, level) need to be taught.profession, as these individuals will end up with poorpreparation for the profession. 4.5. Psychologists’ consultation skills need strength- ening.Recommendation 2 Governments and (by delegation) the Colleges of 4.6. Psychology training programs should teachPsychologists may want to set up or tighten rules basic psychopharmacology as well as knowledge per-about what a psychological practitioner’s minimal taining to psychological effects of drugs given for non-competencies need to be. A recent move towards com- psychiatric problems (like, for example, beta-blockerspetencies-based assessment REFLECTS the spirit of this or antimalaria prevention drugs that are known tosuggestion. Psychologists’ associations can push for trigger psychological symptoms).the right to diagnose and treat and ask that untrainedindividuals be prohibited from such practices. 4.7. Psychology training programs should teach use of electronic technologies for teaching, crisis assis-Recommendation 3 tance, and consultation. Professional associations need to continuouslyinform the public about psychology through the 4.8. Psychology training programs should encour-media and public service activities (like “depression age practica/internships in general health settingsscreening day”) to assure a noticeable-sized dot (rep- (for example, in a family practice setting, medical spe-resenting our profession) on the radar screen of the cialty training setting, or multidisciplinary group set-public and of political decision-makers. When com- ting that sees out-patients).municating with the media, with patients, and withcolleagues, we can and should continually challenge 4.9. Teaching faculty should ideally be trained asthe often glib description of the health-care system as broad health-care providers. This does not mean thatconsisting of “doctors and nurses.” Recall that our uni- all individual clinical/counseling faculty need to beversity trains 11 different health professions! We also experts in all areas of health care. Rather, the comple-discourage the use of the word “doctor” as a profes- ment of the faculty should represent this broad exper-sion descriptor for physicians because it undermines tise. If there are faculty with research interests inour public representation as professionals who have health psychology in a given university, they will beearned their doctorate titles. Historically, “Doctor” most useful for training upcoming practitioners ifrefers to title rather than profession (the word root is they themselves are trained as practitioners, arethe Latin “docere,” which means “teach”), and lan- licensed, and actively participate in teaching appliedguages other than English do not practice this confus- skills.ing habit. Models of Professional Identity and PracticeRecommendation 4 Notwithstanding the above recommendations for 4.1. Psychology as a health-care profession should broadening the teaching programs, delivery of thisideally be taught in a university that trains other material can be discussed as possibly occurring withinhealth-care professionals so that preparation for team two different models, each of which has its own char-work can occur early in the professional’s training. At acter. We believe that we need to clearly define ourleast some classes can be taken jointly by varying identity so as to have consistency between training andhealth professionals. Potentially suitable are courses in practice, to be sustainable even in a changing health-basic physiology, health psychology, aging, medical care system, to allow earnings that reflect the excel-terminology, or a basic course on typical diagnostic lence of the profession’s members and their longprocedures and decision-making in family practice. training, and that allow the public to extract the most
  • 186 Linden, Moseley, and Erskineknowledge and best available skills from our profes- cine. We believe that this model is ultimately moresion. There are two models we put forth for debate: sustainable in light of current competition and chal- lenges within a revised health-care system, and it rep- Model A: The vertical/parallel model. This model resents a better fit with the excellence of current grad-maintains much of the status quo of current Clinical uate students and their superior ability to create, lead,or Counseling Psychology curriculum but adds innovate, and teach.enough to clearly move us from “just a mental health Moving towards this model will take effort at clari-care profession” to “a health-care profession” (as fication to the public and policy-makers; in addition,described and advocated above). This model places psychologists will need to proactively share theirpsychologists into a fully parallel, vertical model where revised self-image with their colleagues in other healthpsychologists are direct service providers (mostly in a professions.one-on-one format) alongside/parallel to the other Many of the suggestions for additional coverage inhealth-care professionals (psychiatrists, social workers, professional psychology university curricula would benurses, occupational therapists, etc.), who all help the equally suitable to strengthen the “vertical/parallelsame patient at various points during a treatment pro- model” as well as the “horizontal/cross-cutting model”gram. but there will be differential emphases and weighing We believe that expanding the current vertical/par- of time invested in specific training components as aallel model for global health care changes only function of the ultimately preferred training model.requires some additions to current curricula, and Irrespective of the reader’s preference for Model A,practicing this model within the health-care system is B, or some third, yet-to-be-described model, a needalready consistent with the image of our profession. for change is apparent and this requires planning andOn the other hand, this model represents a narrow determination. Any major change carries within it theview of the profession of Psychology and continues to risk of creating new problems and (coincidental) dis-directly pitch us against other providers (nurses, mantling of previous strengths. As such, we posit that“counselors,” social workers) who also provide clinical anybody actively involved in this change process con-services and are direct competition; because they cost sider the following caveats.less money to the system, psychologists may lose out asthe closure of entire psychology departments in hospi- 1) It may not be advisable to look too much South,tals has shown. across the border, for helpful advice because the overall health-care politics and the training reali- Model B: The horizontal/cross-cutting model. This ties of the U.S. are quite different, and fewmodel is seen as substantially different than the model Canadians are tempted to emulate the Americancurrently in place. We believe that it maps better onto health-care system. The proposed changes tocurrent training emphases in psychology because it Canadian psychology training need to be continu-more closely resembles the scientist-practitioner ously matched to ongoing changes in themodel that is actually being taught (see Table 1). This Canadian health-care delivery system or evenmodel represents a clear move towards less direct pro- drive such changes.vision of patient services by psychologists (especiallythe one-on-one treatment approach) and seeks to 2) Based on feedback from accreditation visitorsmove away from competition with psychiatrists, or (CPA and APA) to our program, we believe thatnurses or social workers, which is present in the paral- Canadian universities do a fairly good job of pro-lel model. Instead, psychologists would provide a lot viding financial support for their students. Wemore consultation, education, policy-making, train- posit that we have comparatively low attritioning, and administration, and this would occur across rates because our students are not quite as “hardall areas of the health-care system. In this model, psy- up” as some U.S. students, especially those in free-chologists may engage in prevention efforts at a com- standing professional programs where tuition feesmunity or national level, participate in acute care in need to cover the full cost of their education.in- and out-patient settings in multiple roles (like While there is room for improvement in theexperts on pain teams or cardiac rehabilitation teams, Canadian system of graduate student support, weor policy advisors on smoking prevention through warn against giving up our research strengthsmass education), they may become “the” behavioural because it will greatly affect the financial supportresearcher in health-care systems, and represent the of students. Many students seek more hands-onbehaviour change equivalent of the traditional consul- clinical training and less research training, andtation-liaison model of psychiatry and internal medi- would like to see more university-based clinical
  • Psychology as a Health-Care Profession 187 training spots. However, they may not be aware 6) Curriculum changes that make psychology gradu- that a) the research component is what helps ates less competitive in the marketplace, or simply them get fellowship support for their studies, and end up pitching them against other health-care b) makes them unique in the health-care job mar- providers who do similar work but at lower cost, is ketplace. We do not have a viable body of free- not in their best interest. Therefore, if any of the standing, professional programs in Canada, and above suggestions are implemented, we need to we argue that this is because Canadians are track diligently (and over an extended period of unwilling to go heavily into personal debt just to time) whether or not the graduates from such have influence on psychology curricula. programs become more competitive in the mar- ketplace, and simultaneously lobby for changes in3) Many readers will readily agree that some aspects the health-care system that complement these of academic program delivery are uncoordinated broader skills psychologists can offer. and driven by individual faculty preferences (see Arnett, Psynopsis, 2004, 26). While such idiosyn- Correspondance should be addressed to Dr. W. Linden, cracies can create problems, the inherent weak- Psychology/UBC, 2136 West Mall, Vancouver, British ness is greatly reduced in programs that have Columbia, Canada V6T 1Z4 (Tel: (604) 822-4156; E-mail: sought and maintained accreditation. Especially wlinden@psych.ubc.ca). from the students’ perspective, accreditation enhances fair treatment, transparency of expecta- tions, reliability in program delivery, and carries Résumé substantial opportunity for influence. Cet article scrute les réalités de la formation actuelle en Encouraging even more programs to seek accred- psychologie dans le contexte des progrès des systèmes de itation appears to be a win-win strategy. soins de santé globaux, particulièrement ceux du système canadien. Les auteurs soutiennent que l’examen et la révi-4) Making changes to curricula involves many deci- sion du curriculum sont nécessaires pour raffermir la psy- sion-making bodies that tend to pride themselves chologie en tant que profession de soins de santé vérita- on their independence and who do not like to be ble; aussi, un tel examen devrait être proactif et tenir told what to do. This is a “tough nut to crack” compte des changements qui se produiront vraisemblable- because a) provincial governments resist edicts ment dans l’ensemble de notre système de soins de santé. from the federal government on how to adminis- En se préparant aux changements anticipés dans les soins ter health care; b) provincial governments are de santé, il est proposé que des modifications soient reluctant to tell universities what and how to apportées au curriculum de manière à mieux refléter com- teach because they appropriately anticipate resis- ment la psychologie peut contribuer (de manière tance and do not want to get into “micro-manage- générale) à la santé des Canadiens. Deux modèles partic- ment” of universities for which they are ill pre- uliers du rôle futur de la psychologie sont présentés à des pared; c) colleges of psychology are not obliged fins de discussion : a) un modèle parallèle/vertical modi- to consult with universities when making impor- fié et exhaustif qui perçoit les psychologues un peu de la tant changes in registration criteria; and d) psy- même façon que les autres pourvoyeurs de soins de santé chology programs are not obliged to listen to the par opposition à b) un modèle horizontal/transversal plus colleges (... of psychologists) when they make pro- innovateur dans lequel les psychologues apportent un gram changes. Clearly, we are advocating that mélange unique d’éducation, d’innovation, d’enseigne- training programs work hand-in-hand with the ment, de consultation sur le système, de prévention ainsi professional colleges to assure smooth integration que des services directs aux patients souffrant de pro- of training and practice. blèmes physique et de santé mentale.5) For at least some of the things that students want (in particular, extensive and time-consuming References skills training), clinical faculty are often willing to Barrera, M. Jr, Toobert, D. J., Glasgow, R. E., & Angel, K. L. provide these if such efforts were rewarded in (in press). Social support and social-ecological terms of career advancement for the faculty them- resources as mediators of lifestyle intervention effects selves. Alas, clinical faculty are usually embedded for Type 2 diabetes. Annals of Behavioral Medicine. in large psychology departments and have limited Interim Report of the Standing Senate Committee on independence. Social Affairs, Science, and Technology (2004a). Report 1. Mental health, mental illness and addiction: Overview of
  • 188 Linden, Moseley, and Erskine policies and programs in Canada. Ottawa, ON: Psychologist, 50(2), 4-9. Government of Canada. Norcross, J. C., Karg, R. S., & Prochaska, J. O. (1997b).Interim Report of the Standing Senate Committee on Clinical Psychologists in the 1990s: Part II. Clinical Social Affairs, Science, and Technology (2004b). Psychologist, 50(3), 4-11. Report 2. Mental health, mental illness and addiction: Rachlis, M., & Kushner, C. (1994). Strong medicine: How to Mental health policies and programs in other countries. save Canada’s health care system. Toronto, ON: Ottawa, ON: Government of Canada. HarperCollins.Interim Report of the Standing Senate Committee on Trull, T. J., & Phares, E. J. (2001). Clinical psychology, (6th Social Affairs, Science, and Technology (2004c). Report ed.). Belmont, TN: Wadsworth/Thomson Learning. 3. Mental health, mental illness and addiction: Issues and U.S. Department of Health and Human Services (1986). Options for Canada. Ottawa, ON: Government of Positioning for prevention: Analytical framework and back- Canada. ground document for chronic disease activities (p. 17).Kenkel, M. B., DeLeon, P. H., Mantell, E. O., & Steep A. E. Atlanta, GA: Centers for Disease Control. (2005). Divided no more: Psychology’s role in integrat- Vitaliano, P. P., Zhang, J., & Scanlan, J. (2003). Is caregiv- ed health care. Canadian Psychology, 46(4), 189-202. ing hazardous to one’s physical health? A Meta-analy-Lalonde, M. (1974). A new perspective on the health care of sis. Psychological Bulletin, 129, 946-972. Canadians: A working document. Ottawa, ON: Wagdi, P., Vuilliomonet, A., Kaufmann, U., Richter, M., Government of Canada. & Bertel, O. (1993). Ungenuegende Behandlungs-Linden, W. (2004). Stress management: From basic science to disziplin, Patienteninformation und Medikamenten- better practice. Thousand Oaks, CA: Sage. verschreibung als Ursachen fuer die Notfallhospita-Norcross, J. C., Karg, R.S., & Prochaska, J. O. (1997a). lisation bei chronisch herzinsuffizienten Patienten. Clinical psychologists in the 1990s: Part I. Clinical Schweizer Medizinische Wochenschrift, 123, 108-112.